The province’s latest critical incident report details the death of a newborn after forceps were used, a leg amputation after a patient’s transfer for care was delayed, and two separate incidents where a person died after complaints of chest pain that do not appear to have been assessed.

The report covers 33 critical incidents reported to Manitoba Health, Seniors and Active Living between Jan. 1 and March 31, 2018, seven of which are connected to the death of a patient.

One of the chest pain incidents occurred in a personal care home, where a resident had told staff on three occasions that he was experiencing the symptom, but there was no documentation to indicate he has been assessed or treated by a nurse. He went into code blue 12 hours later and died, according to the report.

The other involved a patient who came to an emergency room and explained they had a history of meth use and chest pain. Again, there was no documentation to suggest assessment or treatment took place, but in this case the patient left the ER an hour after arriving, and was found dead in the community an hour after that.

The newborn’s death came after a birth that saw forceps used three times before the infant’s heart rate slowed and a C-section was performed. The baby needed to be resuscitated, but died after two days in a neonatal intensive care unit.

In another incident, a patient suspected of being infected with flesh-eating bacteria saw their transfer to specialized care delayed by 24 hours. The patient’s left leg was amputated, read the report.

A critical incident is defined in legislation as “an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired,” and can take place in settings that include hospitals, personal care homes, ambulances and other facilities covered by the law.

You can read the entire report online.